Normothermic Perfusion Versus Static Cold Storage in Liver Transplantation: A Meta-Analysis of Randomized Trials

Background: Normothermic machine perfusion (NMP) is an alternative to static cold storage (SCS) for liver graft preservation, potentially reducing ischemia–reperfusion injury and improving organ utilization. Methods: We systematically reviewed RCTs comparing end-ischemic NMP with SCS in adult liver transplantation (MEDLINE, EMBASE, CENTRAL to July 9, 2025). Outcomes of interest included early allograft dysfunction (EAD), organ utilization, patient and graft survival, peak AST, primary non-function (PNF), and biliary complications. Results: Four RCTs (801 patients; NMP 418; SCS 383) met inclusion. NMP reduced EAD [16.4% vs. 27.2%; RR 0.61, 95% confidence interval (95% CI) 0.38–0.99; p = 0.05] and increased organ utilization (75.5% vs. 69.4%; RR 1.10, 95% CI 1.02–1.18; p = 0.01). No significant differences were observed for patient or graft survival, peak AST, PNF, or biliary complications, though the latter trended in favor of NMP (RR 0.73, p = 0.07). Conclusion: In adult liver transplantation, NMP reduces EAD and improves organ utilization compared with SCS, without significant differences in survival or major postoperative complications. Evidence remains limited to few trials; larger RCTs are needed to assess long-term benefits.